=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093913691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY FOOT CARE GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2007
-----------------------------------------------------
Last Update Date | 12/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 990 PARADISE RD SUITE 1B
-----------------------------------------------------
City | SWAMPSCOTT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01907-1395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-593-1700
-----------------------------------------------------
Fax | 617-776-3850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 56 OCEAN AVE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01970-4627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-593-1700
-----------------------------------------------------
Fax | 617-776-3850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES W CONNOLLY JR.
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 781-593-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------